The Fate of Obamacare

FOR the first six years of the Obama era, many Republicans made an apocalyptic case against the president’s health care law. It was unconstitutional, immoral, borderline tyrannical. It wouldn’t just fail: It would fail disastrously, in a death spiral that would take down most of American health care as we know it.

Then the apocalypse failed to arrive. The law survived two Supreme Court challenges; it survived the website fiasco during its rollout; it survived the wave of cancellations and premium increases; it successfully enrolled millions of the uninsured.

At which point Republicans, never particularly eager to grapple with the actual details of health care policy, began talking about the issue less and less. Since the government shutdown in 2013 failed to stop the law from taking effect, the word “Obamacare” has lost pride of place in G.O.P. talking points. On the 2016 campaign trail, terrorism and immigration are the hot-button topics, tax cuts once again the big domestic policy promise, and it’s clear that any real health care talk will wait until the general election (if it shows up then). The party’s base just isn’t that excited by the issue anymore.

Yet the interesting thing is that as Republicans have fallen silent, the law’s struggles have actually increased. For a little while after the website righted itself and enrollment picked up, liberal pundits had fun mocking the G.O.P.’s predictions of disaster, and began talking as though Obama’s legacy was established, the law’s success foreordained. But you hear a lot less of that talk nowadays.

First, after the initial surge, Obamacare’s enrollment numbers have mostly disappointed. Not in a catastrophic way — the law has knocked down the U.S. uninsured rate to about 11-12 percent, compared to a pre-Great Recession level of 14-15 percent. But depending on how you cut the numbers, it looks like the Obamacare exchanges will fall at least four million enrollees short of the target for 2016.

Moreover, the people who are enrolling are sicker and more heavily-subsidized than either the White House or the participating insurers had hoped; the healthy uninsured are often choosing to pay the fine (sorry, Chief Justice Roberts, I mean tax) and go without coverage. Which means the initially lower-than-expected premiums charged on the exchanges are headed upward, and major insurers may end up following United Healthcare for the exits if the numbers don’t improve.

It’s much too soon to say if that trend will continue. But congressional Democrats seem to have already lost the stomach for policies that were supposed to not only pay for the law, but bend the wider health care system toward sustainability.

As Yuval Levin pointed out for National Review last week, that’s one clear takeaway from the omnibus spending bill that both parties just negotiated. The bill delays not only Obamacare’s medical-device tax, much hated by industry lobbyists, but also the so-called “Cadillac Tax” on high-cost insurance plans, which was crucial to the health care law’s ambitions to be a deficit-reducing, cost-bending success. When Obamacare first passed, many conservatives expressed skepticism that its “taxes to be implemented later” would actually be implemented; now we have evidence that they were right.

All of this disappointing news, however, does not prove that we’re headed for an apocalypse after all. Obamacare’s lower-than-expected enrollment, for instance, means that the law’s subsidies will cost less than anticipated, so the postponed pay-fors won’t hurt the budget quite as much. And it means that the budget-busting scenario feared by some conservatives (myself included), in which employers find a way dump their sickest or poorest employees onto the exchanges, isn’t likely to materialize.

So despite their problems, the exchanges could stagger along for quite a while as a kind of high-premium high-risk pool attached to our shrinking employer-based and expanding single-payer (Medicare and Medicaid) systems. Which would let both sides claim a modest sort of vindication: Liberals because many of the most sympathetic cases will have access to insurance, conservatives because everyone else’s costs will have risen and the larger system’s underlying problems will linger unaddressed.

In a well-functioning republic, these problems would be addressed next: Both parties would be “thinking past Obamacare,” as Levin puts it, and setting the country up for a debate about the next round of health care reform.

Maybe that debate will happen. But it seems just as likely that the new budget is less a prelude than the sign of a new normal, in which Obamacare is neither fixed nor fully paid for nor furiously opposed, but simply limps along with the rest of our health care system for as long as both can limp.